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We Can Do Better: Aging and the Value of Physical Therapy

2020; Lippincott Williams & Wilkins; Volume: 43; Issue: 3 Linguagem: Inglês

10.1519/jpt.0000000000000276

2152-0895

Dale Avers,

Healthcare cost, quality, practices

I want to share a little story about an encounter I had recently. At the end of a meeting with my attorney, he told me his fiancé was a physical therapist, having graduated in 2016. He then asked me, “Do you think physical therapists will ever get the respect they deserve, and along with that the salary/payment?” Wow! He might as well asked me, “Do physical therapists provide value that is recognized or meaningful? What would you say?” I'm passionate about the potential for our profession—as much now, after 40+ years as when I entered PT school. But have we realized our potential? I would say not. Do we demonstrate value? Not as consistently as we could. I have recently become aware of the reluctance of newly graduated and younger therapists not using their earned title Doctor. How many of you routinely use it as part of your patient care? And if you don't, can you say why? When I ask that question, the 2 most common reasons I hear is a lack of cultural support and that they don't want to appear to be better than those more experienced and who don't have their DPT. It seems our “blue” personalities—that part of us that doesn't like confrontation and wants everyone to feel good—may be getting in our way. And yet, we seem to have no issues with asserting our board certification. Why? But I would also suggest that maybe any reluctance to fully embrace the title Doctor or any other credential is perhaps lower confidence in the potential of physical therapy. Do you practice in a way that demonstrates a passion and belief in the value of physical therapy, in a way that communicates that what you do really will make a difference? What is value? The dictionary defines value as the importance, worth, or usefulness of something. It can also mean having a high opinion of something. The Centers for Medicare & Medicaid Services (CMS) defines value-based care as care linked to outcomes and reflective of the patient's experience of care.1 Do we have personal confidence that physical therapy in general or our individual care specifically provides value? Perhaps many of you feel like you are still growing into your Doctor title and not wholly confident of the value physical therapy can provide to our patients and to society. That is what I want to talk about today. But first, let me say it is one of my greatest honors to be chosen as the second Carole B. Lewis Distinguished Lecturer for the Academy of Geriatric Physical Therapy. I thank the Academy's leadership for having the faith in me that I will deliver a meaningful lecture (we'll see!). I'd like to acknowledge the many students, educators, and clinicians with which I've had the privilege to teach and interact. I would not be here today without your encouragement and support. And I especially want to thank some folks that have had a special significance on my professional life. Without question, Dr Carole Lewis has been one of my most influential mentors. We started in the Academy within a couple of years of each other and so I got to know her very early on in the Academy's history. She brought enthusiasm and passion to her teaching and her positivity to improve the lives of older adults resonated with me. She was such a natural, charismatic leader (some of you will remember the hats) that I felt compelled to follow her. She passionately and expertly shared evidence that focused the practice of physical therapy on what could really make a difference to the individual. Thank you, Carole, for providing the example and inspiration for me and for so many others to serve older adults with excellence and pride. I would also like to thank 3 other influential mentors—Rita Wong, Marybeth Brown and Andrew Guccione. They have taught me so much, from our first meeting writing questions for the first Geriatric Certified Specialist (GCS) examination to collaborating on 2 editions of 2 books. They are all great models of aging and their friendship means everything to me. However, the person who inspires me the most is my mother, who has given me the great honor of being with me here, this morning. My mother is a kind, intelligent, and gifted educator and leader and I'm proud to be her daughter. She is also a terrific example of exemplary aging. Ironically, her inspiration for how she is aging comes from how she didn't want to age. Her mother, my grandmother, was not a fan of physical activity. As a consequence, although she lived to be almost 100, she was bed ridden the last years of her life. Mom was determined to age differently—and indeed she has. Starting with walking in the mall during her 60s and transitioning to using a treadmill (for weather reasons) around the age of 80, she has engaged in daily physical exercise. She walks on her treadmill at a pace of 4.8 mph for 30 minutes (that's a pace of 1.79 m/s) and engages in body-weight strengthening holding a plank for 2 minutes, performing lunges better than I do, achieving 15 sit-to-stands in 30 seconds, and now includes triceps dips, half Turkish get-ups, and push-ups. This is at the age of 89.5 years! She also teaches an exercise class! My biggest issue is she has set the bar so high, it is making my aging more difficult! Mom, I love you and admire you so much. Please stand up and be recognized. This is undoubtedly the most daunting talk I've ever done ... to deliver a 90-minute (for the record, 90 minutes was not my idea, but true to my nature, I've filled every minute of it) lecture that shares a bit of my journey and then something profound enough to change/nudge/stimulate your own journey. But let me begin. My earliest view of aging was influenced by my grandparents—who fortunately, were all healthy well into their very old age. Growing up, I didn't see disability or decline, and I think this helped me avoid a fear or distaste for older people. Geriatric physical therapy wasn't something you “went into” when I was in physical therapy school at the University of Kentucky. But my first job was in a nursing home, albeit unintentionally. However, I learned so much there, working as the only therapist, and under a visionary nursing home administrator. But it didn't take long to recognize there wasn't much joy in the place, in spite of the efforts being made—and we spent a lot of time talking about reasons for the climate of long-term care. I even got my nursing home administrator's license thinking that might be a pathway of changing the culture. I think the question that started at that first job, and has stayed with me, is “why are these people here? No one seemed to want to be here, so what happened?” That basic question has driven my professional practice. I wanted to help older individuals avoid nursing homes, and to educate physical therapists and students to have higher expectations than “dragging someone down the hall” (now we push them on their rolling walkers). Then, after 15 years of clinical practice, I was encouraged to have more influence on other therapists and turned a corner into academia where my goal has been to change practice for the better. I suppose the goal of changing practice for the better is similar to my desire to facilitate successful aging for every aging adult. But what is successful aging? It is a complex topic with no clear definition and a lot of critics rightfully poke holes into any definition. So, to avoid that controversy, I'm going to use the term “intentional aging.” Intentional aging is deliberate, of making decisions about how one wants to age, of adapting in positive ways to the changes aging brings. Yet, so many older folks are passive about their aging. I think the opportunity for us to engage in a proactive approach to facilitate and support intentional aging is immense and I want to share some ideas about how physical therapists can do that. I also want to share a bit about shifting paradigms of practice, which can enhance or undermine intentional aging. And then, finally, I'm going to talk about a few things, ok, it might be more than a few things, that we can do better, that can make our practice better, and that demonstrates the value of our profession. The objectives for this lecture are: Following your active attention in this lecture, you will be able to: Reflect on the value of physical therapy for older adults Recognize the consequences of implicit bias in the physical therapy delivery of older adults Recognize the implications of common models of aging on the delivery of care on chronic disease management and intentional aging Gain awareness of societal approaches to aging that are enhanced with physical therapy Reflect on proposed standards for the provision of geriatric physical therapy Have a benchmark to self-assess your delivery of care PARADIGMS OF AGING We have an image program in geriatrics. That image is too often the perspective of decline and decay as aging. Most of us are aware of the often negative reaction generated when aging is mentioned. For fun, I made a list of all the words used to describe aging that began with D. Just look at them (Figure 1)!Figure 1.: Decline and Decay Model: The D's of Aging.Aging is often used as an excuse, “I'm just getting old” or as a negative prophesy, “I won't be able to do stairs someday.” As an active physical therapist, I am frequently struck by these views, as if they have nothing to do with the outcome. Aging seems to be something folks let happen, without a lot of thought. Yet, most of the health problems of older age are exacerbated by inactivity and deconditioning, intentional factors. In fact, depending on the source, 60% to 70% of a person's health is due to factors we can influence, if not control, such as social, behavioral, and environmental factors at any age. That means the decisions we make (whether they are active or inactive decisions) have enormous influence on our health especially in how the fourth age of our lives will look, when the end of life is near, says geriatrician Louise Aronson in her book Elderhood.2 I love visiting my mom at her retirement living complex—for lots of reasons, but especially because of all I learn. We have the best talks about aging and how and why different people age. Aging has so many faces, so many presentations, and I can't help but wonder what accounts for the differences. The more I spend time as a visitor, the more I believe aging intentionally comes down to attitude. An attitude of perseverance or an attitude of giving in and giving up. My mother shared an insight that perhaps the folks we see in assisted living and retirement centers who seem to be aging passively and becoming frail expend the effort and work, such as exercising and being physically active, that was necessary to stay in their homes; but then an event happens, a spouse dies, an illness occurs that makes it impossible to stay ... and they make the huge transition to a more “protected” lifestyle that reflects the acceptance of gradual and increasing dependency. This acceptance often includes a largely sedentary existence and rarely includes exercise. Her insight aligns with the lived experience of elders that indicates as long as they are actively engaged in the process of living, of fighting against the desire to give up and give in, they do not believe they are frail, despite any physical characterizations.3 If this is so, it means as physical therapists, we need to adjust expectations to make sure they are reflective of the older person's expectations, and that we enhance their capacity where they choose to be. The adaptation to some form of dependency also means we need to encourage the building of reserve in the third age—in the 50s, 60s, and 70's to prepare and support the fourth age when the physical and cognitive reflections of age become more obvious. Much of how we age is a choice, is intentional. Living intentionally, and having purpose, whether its engaging in exercise, socialization, volunteerism, projects, business etc., or as may be for some ..., adapting to limitations in capacity; seems to be the critical factor in aging successfully. I am impressed with how my mother and several of her friends take care of each other, help each other, growing in their interdependency as they adapt to reduced eyesight, limited mobility, and declining memory. Their adaptations are intentional, and physical therapists impact this through our focus on function and mobility. Good health is the great enabler of a long, happy, and meaningful life.4 Without it we lack the energy and drive to pursue happiness, to carry out our daily roles and responsibilities, to work and volunteer, to engage in meaningful relationships, and to stay engaged in society. Yet unhealthy behaviors remain prevalent among older people, and health systems are poorly aligned with the needs of older populations who have multiple chronic diseases. Individually and societally, we seem to be ignoring the opportunity to positively influence our own aging and the health of our aging clients. Instead medicine seems to operate from a mechanistic model: fixing and replacing parts at will in single episodes of care, without a thought to the context of the patient's remaining life or even continuum of care. Too often the focus is on treating age as a disease, as something to be fixed rather than how to improve capacity within the context of multiple chronic diseases. But aging can't be fixed, can it? And replacing a body part, say a knee or hip, doesn't mean the body will be as good as new. So how do we as physical therapists avoid the trap of the mechanistic model, the inclination to “fix” things rather than manage them? In short, how do we build capacity in the third and fourth stages of life? Ageism is seen in the traditional expectations of how we are to live our older years. Do we regard a 75-year-old as “special” or “usual” if she actively exercises, hasn't withdrawn, slowed down, or otherwise become diminished? If the added years science and technology have given us are spent in good health, people's ability to do the things they value, that matter the most, will have few limits. However, if these added years are dominated by declines in physical and mental capacities, the implications for older people and for society may be much more negative. Jo Ann Jenkins, the CEO of AARP, discusses the opportunities that come with longevity in her book Disrupt Aging.4 She suggests the gift of increased longevity presents possibilities of fulfillment, legacy, and health. She believes the majority of older people approaching traditional retirement age, say the third age, do not actually want to retire in the traditional sense. Rather, they want to remain active participants in society, even continuing to work in some capacity. Combining good health and function by building capacity and disrupting the decline and decay perspective of aging may allow greater and prolonged productivity, either in the workforce, volunteer activities, in one's family, etc, and thus benefit the individual and society. Physical therapists help folks live these extra years with purpose and adequate functional mobility, expanding the active years and compressing and lessening dependency. This is value. We must also check our paternalism and low expectations that we may implicitly communicate. Why do we ask “are you tired” or if a person needs a rest when we are taught how to observe and measure physiologic and motor signs of fatigue? And what about our expectations for strength? Do we know what the average amount of weight an individual over 65 should leg press? Do we even have access to a leg press? Or do we make excuses? In short, do we expect that our older patients/clients have the capacity to be strong, steady, active, and participating adults? I still get reasons from therapists for not using high-intensity strengthening for patients/clients of “too fragile, unwilling, or too old.” Indeed there may be some unwillingness on the part of patients—but that's the challenge in front of us, because we know the evidence. It is still too common to see therapists start with a minimalist goal of returning the patient to their prior level of functioning when that prior level in all likelihood precipitated the current health care crisis. Other ways we implicitly demonstrate aging bias is prescribing a walker for balance instead of poles to compensate for balance issues or having the expectation of diminishment. We have a challenge in that we interact with a diverse group of elders with differing needs and abilities. We may have individuals who are seeing nothing but possibilities in their retirement and want as much physical capacity as possible and we see folks edging toward the end of their life. That means we must reset our expectations every time we see a different patient. Any reduced expectations limit our capacity to help our patients age and function to their desired capacity level. Reduced expectations also feed into or reinforce the low expectations an older person may have for their own aging. Low expectations for the aging process and for the capacity-building of older people has no place in communicating the value of what we do and what we have to offer aging adults. This is a good time to reflect on how you want your own aging to be, to explore your personal expectations—and then do something that will achieve them! I am pleased that the Academy of Geriatric Physical Therapy has been exploring the need to change the old paradigm and pursue a future that embraces and seeks opportunities to communicate and deliver value through physical therapy services. For the better part of the year, they have been working on a total rebranding that is quite visionary—and the unveiling happens tonight. I can't wait to see and hear! SOCIETAL AGING PARADIGMS At a societal level, there is a lot of interest in developing new aging paradigms that are more appropriate for the increased longevity being experienced and for the presence of chronic diseases that need to be managed, rather than fixed. These models emphasize goals of active engagement and empowerment, in short, capacity building. Each of these models implicates the role of physical therapy, and offers us an opportunity to demonstrate our value. Let's take a look at 3. The Healthy Aging in Action model of the National Preventative Council5 addresses the policies that are needed to advance a healthy aging paradigm. Their goal is to advance healthy aging. Healthy aging is defined as the promotion of health, prevention of injury, and management of chronic diseases; of optimizing physical, cognitive, and mental health; and of facilitating social engagement. I like the way the National Prevention Council states the challenge: “We need to create a culture where older adults are viewed as vibrant, important, and productive members of society.” One of the premises of the National Aging in Action model is that most Americans want to live independently and remain in their own homes and chosen communities as they grow older. Some of the initiatives that are related to physical therapy include: provide information about healthy options, support and empower informal caregivers to promote healthy aging, increase access to preventative services, develop fall prevention programs, train physicians and others health care professionals on age-related health issues, and expand the availability of home and community-based services. For example, helping folks age in place is a way physical therapists demonstrate value to society and to patients and their caregivers and families. Another goal is to expand fall prevention programs. As physical therapists, we should be leading in this area, implementing best practices in community-based fall prevention efforts while increasing access to those programs. The National Prevention Council model includes many other goals that implicate physical therapy that we would do well to formally address and that would promote our value. The World Health Organization's (WHO's) Active Aging Framework6 is the second model I share with you because of the integral role of physical therapy. The WHO has defined healthy aging as the process of developing and maintaining the functional ability that enables well-being in older age. They have gathered energy and purpose around healthy aging to ensure that “older persons remain a resource to their families, communities and economies.” A focus of their Framework is promoting social engagement. And since there is a strong relationship between social engagement and mobility, social engagement may be a way of measuring physical therapy value. If someone cannot mobilize outdoors, and cannot negotiate transportation, then the risk for social isolation occurs, and frailty can result. Physical therapy is integral to the WHO's Active Aging Framework of healthy aging. The 4Ms Framework is the third and last model I want to share. It is aimed at the challenges that the sequela of chronic conditions presents, especially in the acute care setting. The John A. Hartford Foundation and others recognized that older people suffer a disproportionate share of harm because of the lack of recognition of the consequences of chronic diseases. They have created a social movement whereby all care for older adults is age-friendly care. Age-friendly care is defined as following evidence-based practices, causing no harm, and aligning with What Matters to the older adult and their family caregivers. The evidence-based elements of high-quality care are called the 4Ms. The 4Ms are What Matters, Medications, Mentation, and Mobility. I don't know about you but I see physical therapy all through this model, so let me elaborate a bit. What Matters to the patient is about truly knowing the person's desires, hopes, and dreams. Ideally, this is documented from the beginning at the Welcome to Medicare visit or any annual wellness visit, so the entire team is aware of what is important to the individual and can deliver care in concert with these desires. The focus on Medications advocates for the judicious use of medications so that they don't interfere with what matters to the older adult or mentation across the settings of care. Mentation involves the active management of dementia, depression, and delirium across all the settings of care. And the fourth, Mobility ensures that older adults move safely every day to maintain their function and to achieve what matters to the person. It involves regular and ongoing mobility screening. The 4Ms are so integral to inpatient therapy that we must be advocates for the model, encouraging its use in our hospitals. So there we have 3 exciting models that address the complexity of aging from a variety of perspectives—but that all implicate the value of physical therapy. Even the surgeons have recognized the need to “do better” by our older folks. The American College of Surgeons has developed the Geriatric Surgery Verification7 that presents 30 new surgical standards designed to systematically improve surgical care and outcomes for the aging adult population. The standards outline a process for systematically improving older adult surgical care (Figure 2).Figure 2.: American College of Surgeons Geriatric Surgery Verification Standards.EXEMPLARS FOR GERIATRIC PHYSICAL THERAPY PRACTICE I believe the physical therapy profession can do better by our aging folks as well. And perhaps our own set of standards or exemplars will help. Let me say I enthusiastically applaud the Academy's efforts to recognize geriatric physical therapists as the exercise experts for older adults. With the excellent CEEAA course and its new partner, the Advanced CEEAA, physical therapists have a valid way of obtaining the knowledge and skills required to expertly deliver our most important intervention, exercise! I understand the Academy is launching a fall prevention certification. I also applaud the Academy's support of research—which we've done for over 40 years. The Academy is advancing the knowledge of evidence to inform best practices in geriatric physical therapy, the noblest of efforts. It is also advancing an initiative of creating academic standards for geriatric education following the example of the Academy of Neurological Physical Therapy. And, in 2011 the Academy of Geriatric Physical Therapy approved a list of competencies in the care of older adults for entry-level physical therapists.8 But this document is now nearly 10 years old. It deserves to be reviewed and updated within the contexts of the models I've just presented and from the perspective of adding value to physical therapy practice. One of our greatest limitations in this marvelous profession of ours is the variability of physical therapy care, which can negatively affect our value. There is no way for the public to know how to determine the quality or how to identify a high-quality geriatric physical therapist, or even what to expect. In other words, our value is hiding under a bushel basket. In part, this is because we don't have a unifying approach or paradigm to aging—some of us have adopted the mechanistic model of fixing,9 perhaps creating fear while we are doing it by using phrases like, “bone-on-bone,” “stop when you feel pain,” and “slow down”; while others have embraced the building capacity model by encouraging patients to do more and facilitating adaptation. Building capacity means promoting and strengthening one's abilities, which may mean providing the skills to adapt to retain abilities based on the individual's expectations and desires for function, activity, and participation, regardless of setting. I believe the building capacity model directly relates to older adults' self-perceptions and is the model that provides the most value to society. But to achieve this value, we need some consistency of practice. Therefore, I believe we need to establish a set of exemplars or standards that are informed by evidence, the models I've just described (the Healthy Aging Initiative, WHO, the 4Ms Framework), and of course the vision of the Academy. And once these exemplars are established, they need to be integrated into every entry-level program. They also could be used as benchmarks by physical therapists throughout their professional practice lives. Remember the APTA list of 5 interventions that consumers should avoid? The second one was avoiding underdosing of strength programs for older adults. While these 5 interventions form the basis of APTA's Choosing Wisely Campaign—-they are stated in the negative and don't help consumers know what to look for. The Academy can be bolder in setting forth our own lists of exemplars or standards as guidelines for the physical therapy care of older adults and publicized as a way of demonstrating our value. The Academy of Neurologic Physical Therapy has done this through their Clinical Practice Guidelines and may be a useful model for us. Exemplars can inform quality benchmarks that quantify our value and promote consistency of practice. With these exemplars, consumers can shop for effective practitioners and know what to expect from a physical therapist. Exemplars can be used by educational institutions to inform the geriatric content in the curriculum. The continuum of care, that is all settings, should reflect these exemplars. The bar needs to be high. It's the only way we are going to grow and mature as a specialty area, to meet the diverse needs of the country's older adults and thus to demonstrate our value. To that end, I'd like to share my ideas for exemplars. This list is meant to be a starting point for discussion and debate. I encourage you to think about what you believe are quality indicators that will demonstrate our value to society. When this lecture is published, there will be a mechanism for you to share your ideas and thoughts. Regardless of our agreement, we need to be fearless about offending those less passionate and not get stuck in perfectionism. These exemplars can help us boldly proclaim all we have to offer, that is to demonstrate our value. We must do better. We can do better. Ready? My proposed 5 exemplars are that the physical therapist working with older adults: Possess an expertise about the aging process and geriatric physical therapy that is continually modified, reflected upon, and shared. Practice person-centered care within a capacity-building paradigm. Conduct a comprehensive evaluation that is informed by meaningful outcome measures and screens for vulnerabilities. Perform best practice and evidence-based interventions implemented with creativity, appropriate challenge, and relevance, which empowers and achieves what matters the most to the patient, and Advocate for the role of physical therapy to promote intentional aging across the continuum of care. Allow me to elaborate on each of these proposed exemplars that could be used to inform best practices for older adults. First, the geriatric physical therapists possess an expertise about the aging process and geriatric physical therapy that is continually modified, reflected upon, and shared. To help build the foundation for this expertise, I believe all physical therapist education curriculums should have substantial aging content that is based on best practices. I believe the profession as a whole will benefit from a standardized geriatric curriculum that is grounded in the current evidence and in best practices. And we can also do a better job in implementing the evidence for how educational practices can reduce ageism. In a systematic review of educational interventions for students, 88% of the studies successfully reduced ageism.10 Perhaps a continuing education course is needed in how to effectively teach geriatrics. It so irks me that a unique course in geriatrics is not required by the Commission on Accreditation in Physical Therapy Education (CAPTE) (unlike pediatrics) in spite of nearly half of all patients in